Personal Health History – Sayville Chiropractors

Date

Name *

First

Last

Email *

Date of Birth

Home Phone

Cell Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Martial Status

Spouse's Name

Spouse's Age

Children's Names & Ages

Occupation

Name of Employer

Hobbies

Who Referred You?

Name of Previous Chiropractors

When was Your Last Visit?

For How Long Were You Receiving Chiropractic Adjustments?

Reason for Coming In

What accidents have you had? (ex. bicycle, car motorcycle, sports, slips/falls) at work or at home, please include dates

Were you ever knocked unconscious?

What fractures or broken bones have you had? (Include dates)

What major surgery have you had? (Include dates)

What minor surgery have you had? (ex. Tonsillectomy, Appendectomy, Wart/Cyst Removal, Dental Extraction)

Present Prescription Drugs

Past Prescription Drugs

Over-the-Counter Drugs

Aspirin, Cold Tablets, Cough Syrup ect...

Personal Health History Form